office of state treasurer

request for public records

							Date . . . .
							Time . . . .
requested by:
Name . . . .					Title . . . .
Address . . . .
Telephone No. . . . .					Representing . . . .
nature of request:
. . . .
. . . .
. . . .
detailed description of document:
. . . .
. . . .
. . . .
					. . . . . . . . . . . . . . . . . . . . . . (Signature)
	——		for office use only				——
(1)	Request Granted □			Record Withheld □			Record Withheld in Part □
(2)	If withheld, name the exemption contained in section 31, chapter 1, Laws of 1973, which authorizes the withholding of the record or part of the record: Subsection (1)( ).
(3)	If withheld, briefly explain how the exemption applies to the record withheld.
(4)	If request granted, time . . . . . . . . , date . . . .
Reviewed: . . . . Public Records Officer (Initial)
		. . . . (Initial)				Deputy or Assistant State Treasurer